Key to saving lives of patients with acute cardiac ischemia (ACI: including acute myocardial infarction [AMI] and unstable angina pectoris [UAP]) is the timeliness of treatment, a major focus of emergency medical service (EMS) systems and emergency departments (EDs). Time is especially critical for patients with evolving electrocardiogram (ECG) ST elevation MI (STEMI), for whom coronary reperfusion therapy (CRT), i.e., thrombolytic therapy (TT) and primary percutaneous transluminal coronary angioplasty (PTCA), can be life-saving, if given promptly. EMS personnel have an appreciation of the importance of time and identification of patients who need acute CRT, but unlike in hospitals, EMS settings have not had requirements for, nor the growth of, quality-improvement (QI) and error-reduction systems. Based on a system we have implemented in hospitals, we propose to implement and demonstrate a cardiac care medical error-reduction/QI system in EMS systems, targeting time to treatment for ACI/STEMI. [unreadable] [unreadable] Our approach to Ql/error reduction is based on the use of time-insensitive predictive instruments (TIPIs) built into the tool used in the first evaluation of the patient with suspected ACI, the computerized electrocardiograph. These electrocardiographs provide the 0-100 percent predicted probabilities of key diagnoses or outcome by printing them on the ECG to aid the clinician's real-time decision-making. The ACI-TIPI computes a patient's probability of having ACI and the thrombolytic predictive instrument (TPI), the probabilities of key CRT outcomes. Also, these probabilities can be saved in a TLPI information system (TIPI-IS) database to be used to generate retrospective reports for feedback. These will be used to target lapses in timeliness of treatment of ACI/STEMI by EMS and receiving hospitals' EDs. [unreadable] [unreadable] Partnering with the country's largest ambulance company (AMR) and largest EMS electrocardiograph manufacturer (Medtronic), and EMS systems and receiving hospitals in Brockton and Springfield (urban and rural settings), Massachusetts, we aim to implement and measure the impact of this EMS cardiac care Ql/error-reduction system on the occurrence of errors and avoidable delays in EMS care and in use of CRT for STEMI in hospitals. As we have done in ED settings, using a before-after time-series quasi-experimental design, we intend to demonstrate the usefulness of an EMS TIPI-IS cardiac Ql/error-reduction system for care for EMS patients with symptoms suggestive of ACI and for the use of CRT for patients with STEMI. Also, based on detailed assessment of user and organizational barriers and incentives for using the system, and intentional transfer of the system's operations and data collection processes to the EMS and hospital sites, we intend that the project make significant steps toward the wider adoption of the approach. [unreadable] [unreadable]